Increases in managed care and competition have undercut hospitals' ability to provide care to uninsured Americans. Massachusetts, New Jersey, and New York use uncompensated care pools to spread the financial burden of providing charity care across hospitals. This paper finds that over time these states have narrowed pool coverage from all uncompensated care to indigent charity care only, have broadened pools' revenue base from hospital assessments to include other revenues, and have begun seeking ways to replace hospital care with more efficient ambulatory services. While pools do not rival comprehensive insurance coverage in funding full access to health care, the authors conclude that they are an affordable mechanism to fund improved safety-net access.